Tuesday, December 17, 2013

Itching in pregnancy - Don't ignore it!

Mild itching from time to time in pregnancy can occur due to the skin being stretched or due to the increased blood supply. 

However, if the itching becomes intense and spreads from your tummy to other areas of your body often occurring on your hands or feet, it is important to let your midwife know immediately because a blood test can be done.  

What is obstetric cholestasis?
Obstetric cholestasis is a rare complication of pregnancy.  It is sometimes called Intra-hepatic cholestasis of pregnancy.  A build-up of bile acids in the bloodstream causes a persistent itch in the last trimester, usually after 24 weeks but it can develop earlier.

It is a condition of the liver which occurs in some pregnant women.  Cholestasis means there is a reduced flow of bile down the bile ducts in the liver, some bile then leaks out into the bloodstream, in particular, the bile salts. These bile salts circulate in the bloodstream and can cause symptoms such as itching.  

Who gets Cholestasis?
It occurs in about 1% women (Australia).  It is more common in women carrying twins or triplets. If you have cholestasis in one pregnancy, you have a high chance of it occurring in future pregnancy.  

What cause obstetric Cholestasis?
The exact cause is not clear.

  • Hormonal factors.  Pregnancy causes an increase in oestrogen and progesterone hormones.  These can affect the live in a way which slows down the rate of bile passing out along the bile ducts.  Some pregnant women may be more sensitive to these hormones.
  • Genetic factors.  Obstetric cholestasis seems to run in some families (although they may skip a generation).  One theory is that women who develop obstetric cholestasis may inherit a slight problem with the way bile is made and passes down the bile ducts.  This does not matter when not pregnant, however, the high levels of hormones made during pregnancy may tip the balance to cause a much reduced flow of bile.
There may be other environmental factors which contribute.  Whatever the underlying cause, pregnancy triggers the problem.  Within a week or so after giving birth the symptoms clear and there is no long-term problem with the liver.

What are the symptoms of obstetric cholestasis?
Typically the symptoms occur after 24 weeks of pregnancy when the  hormone levels are at their highest. Sometimes it develops earlier in the pregnancy.
  • Itching is the most common symptoms and this can be all over the body, often worse on the hands and feet.  Commonly it is the only symptom and tends to become worse until you have your baby.  The itch can become severe and affect sleep, concentration and mood.
  • Tiredness
  • Poor appetite
  • Mild jaundice.  you may go yellow and have dark urine and pale stools.  This is uncommon and due to an increased level of bilirubin (part of bile) leaking from the bile ducts into the blood stream.
Is obstetric cholestasis serious?
The symptoms can be unpleasant for the mother, in particular the itching.  Further research is being carried out into the risks of harm to mother and baby, it is thought that obstetric cholestasis causes an increased risk of stillbirth and fetal distress.  

There is a higher chance of your baby opening his bowels in the amniotic fluid (water surrounding your baby) and can irritate the baby's lungs if breathed in during labour.

A blood test
This can detect the raised level of bile acids and liver enzymes in the blood.  

What is the treatment?
There is no cure for obstetric cholestasis other than the birth of your baby.  You may have a blood test every two weeks to check your liver.  The obstetrician in collaboration with your midwife and you will advise on the best plan for you and your baby.  

Your obstetrician or GP may prescribe Ursodeoxycholic acid which boost liver function and reduces the itching.  

The obstetrician may decide that your baby should be induced or birthed earlier usually about 37 weeks (can be earlier depending on the bile salt levels) rather than waiting for you to go into labour naturally.  More research is being done into the risks and effects of the condition and treatment.  

Please let your midwife know if you get any itching in pregnancy.

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